General Surgical Consent Form (Page 2 of 2) in pdf

Are there any concerns or questions regarding your pet that you would like to discuss with the

doctor?__________________________________________________________________________

Does your pet have any sensitivities or allergies to any medications?_________________________

All patients left in our care for any reason must be current on Rabies, DHLPP, Intra and

FVRCP.

If proof of vaccination is not available, I give my permission for the staff of

Blackhorse Animal Hospital to update my pet’s vaccinations.

According to our records your pet will be due for; Rabies, DHLPP, Intra, Lepto, DHPP, Canine

Influenza H3N8 , FVRCP and FELV

All current/ new patients are required to have physical yearly exam, with our Doctor within one

year, at an additional cost of $60.00 _______ Int.

I have been advised as to the nature of the procedure or surgery described above and the

risks involved. I authorize the use of appropriate anesthetics and medications that are needed

to perform these procedures or surgeries. I realize that results cannot be guaranteed, I further

realize that I am responsible for full payment at time of discharge.

I understand that

unforeseen conditions may extend the procedures or surgeries and that if this happens,

Blackhorse Animal Hospital staff will try to contact me to discuss these conditions. If I cannot

be reached, I consent to having Blackhorse Animal Hospital take the steps necessary to help

ensure the safe care of my pet.

Signature: ___________________________________________

Please give all phone numbers that you or your spouse will be available:

Home Phone: ________________________________

Cell: _______________________

Work Phone: _________________________________

Other: _______________________

13203 Fry Road, Suite 1200

Cypress, Texas 77433

832-220-1380 or Fax 832-220-1385

General Surgical Consent Form Page 2